The present invention relates to a set of tools for suturing in deep surgical apertures or body cavities and comprising: a needle driving device having an elongated needle holder support member and a needle holder with a channel for accommodating a curved surgical needle provided with a thread, which needle holder is arranged at one end of the elongated needle holder support member which comprises an elongated member with a flexible foremost end for driving the needle out of the needle holder, and a gripping member, e.g. a pair of tongs, for gripping and extracting the needle into a position outside the surgical aperture or body cavity.
Up to now, it has been difficult to perform a suturing in deep surgical apertures or in deep body cavities. A manuel insertion of suturing needles has ordinarily been effected by means of a pair of tongs or special needle holders. This has necessitated the formation of large surgical apertures in order to have sufficient space to insert the needle through the tissue in the position desired in order to arrange the thread in a correct manner.
Different kinds of tools for suturing in deep surgical apertures or body cavities are known. An example is known from U.S. Pat. No. 3,946,740. The tool described is a tong-like instrument which makes it possible to suture in a region in which a surgeon will have difficulties in inserting the needle through the tissue to be sutured. From U.S. Pat. No. 4,935,027 a thread conducting member is known which comprises a tubular structure being slotted. This member is rather voluminous and difficult to use in small apertures.
However, the prior art tool requires that the tissues to be sutured are maintained so as to position them correctly for clamping between the two jaws of the tong-like tool. The tissue should be flap-formed so as to allow them to be arranged between the jaws which contain a needle driving instrument and a gripping member, respectively for gripping and extracting the needle after its passage through the tissue.
The suturing tool described can only be used in surgical apertures into which surgeons have a direct access and which have a sufficient size to allow other auxiliary instruments to be introduced to maintain the tissue in position. Thus, it is a drawback of the suturing tool described that it only has a limited area of use.
It is the object of the present invention to provide a tool of the type described in the introductory part which allows a surgeon to suture in smaller regions or through smaller apertures than it has previously been possible.
According to the present invention this object is achieved with a set of tools which is characterized in that the needle holder is mounted pivotally at said one end of the elongated needle holder support member, that actuating means for pivoting the needle holder and the flexible foremost end of the needle driving member are provided at the other end of the elongated needle holder support member, that the set of tools further comprises a thread conducting member having an elongated thread guide support member with two prongs arranged in V-shape arranged at one end of the elongated thread guide support member which at its other end is provided with a handle and that thread guides are constituted by means in the free end of each of the prongs.
Due to the elongated support members which may be flexible or rigid members, the set of tools according to the present invention permits an operation in deep surgical apertures or body cavities. The depth of the surgical aperture is solely determined by the length of the elongated support members. As the needle holder is pivotally mounted at the one end of the elongated needle holder support member, it becomes possible to introduce a curved needle without requiring a flap-formed shape of the tissues to be sutured.
The pivoting of the needle holder is actuated from the other end of the elongated needle holder support member. This allows the needle holder having the point of the needle positioned immediately outside the curved channel to be introduced into the tissue at one side of the opening or wound to be sutured. Through the pivoting, the initial introduction of the needle will be effected in a direction substantially perpendicularly to the surface of the tissue. During the initial pivoting the needle is conducted through a circular path in direction towards the opening to be sutured. When the point of the needle has been pivoted through an initial part of the path, the remaining movement of the needle is effected by means of the needle driving member contained in or constituting a part of the needle holder support member.
When actuating the needle driving member, the needle will, due to its curved form, continue its travel along a curved path through the tissue at the other side of the opening to be sutured until the needle has been pushed completely out of the needle holder. At this stage at least the point of the needle will be conducted to a position above the tissue. In this position the needle may be gripped by gripping members and then pulled out into a position outside the surgical aperture or the body cavity. After the needle has been pulled outside the surgical aperture, the connected suture thread and the free end of the suture thread will be situated outside the surgical aperture.
This implies that the thread should always have such a length that both ends can hang freely outside the surgical aperture or the body cavity irrespective of its depth. The gripping member may be built together with the needle driving tool or may be constituted by a separate pair of tongs.
Then the thread conducting member is used. An initial knot is made by conducting the two ends of the thread around each other outside the surgical aperture. The initial knot is subsequently pushed closely into the tissue, the two separate thread guides in the free end of each of the prongs being placed at each side of the initial knot on the part of the thread facing towards the free ends. As a result, the thread conducting member may push the partial knot completely into the tissue. The thread conducting member is then pulled out and the ends of the thread are once again conducted around each other in order to complete a knot. The two separate thread guides are then again arranged on the free ends of the thread and the further binding of the thread is conducted down into the tissue in which a final knot is formed which is tightened by pushing the thread guides forwards while at the same time exerting a backwards pull in the two thread ends. As the thread guides are separated this will cause a tightening of the knot due to a substantially opposite directed pull in each of the two ends of the thread. Then the thread may be cut immediately outside the knot either by means of a separate pair of scissors or by means of cutting members which may be actuated from outside and which are connected to the thread conducting member in close proximity to the thread guides.
The set of tools according to the present invention may be used in connection with commonly known flexible scopes. The tool e.g. makes it possible to effect a suturing in the stomach by means of a modified gastroscop which is arranged to accomodate a set of tools according to the invention. When flexible support members are used, these are preferably provided in the form of one or several tubular hollow casings containing one or several casings or wires used for performing the different work procedures by operating the actuating means via a handle outside the surgical wound. Thus, the different casings and wires are mutually displacable. Inside the casing light sources and optical instruments may also be arranged so as to allow the surgeon to monitor the suturing from the outside.
When rigid substantially rectilinear support members are used, these members may also be constituted by one or several mutually displacable casings which both are connected to actuating means in a handle and to the movable parts of the tools.
Irrespective of which embodiment is used it is necessary that the outermost end of the needle driving member is flexible so as to allow it to follow the curved channel in the needle holder when the needle is to be pushed completely out of said needle holder.
As mentioned above the thread conducting member may optionally be provided with cutting members arranged in close proximity to each thread guide. The cutting members may preferably be provided in the form of a pivotal cutter coacting with a counter cutter in the slot or the eye of the thread guide. Via connecting members the pivotal cutters are connected to an actuating bottom in the handle of the thread conducting members. The application of such cutting members may be omitted in a thread conducting member of the type manufactured with a rigid support member. This is possible as it most often will be possible to cut the two ends of the thread by means of a pair of scissors, even in relatively deep surgical apertures. Vice versa the cutting members will be advantageous in connection with thread conducting members having particularly long, flexible support members. It will be time-consuming to have to pull out the thread conducting member and then introduce a succeeding separate cutting member through a very long support member.
Thus the set of tools according to the invention will does not replace any prior art set of tools. On the contrary, the set of tools constitutes a supplement to prior art suturing tools. The set of tools makes it possible to perform an operation which up to now has been considered impossible, e.g. ruptured eardrums. The set of tools may also be used to facilitate operations in the knee, e.g. when suturing the foremost ligamenta cruciata.
In practice, the set of tools according to the invention may be introduced through tubular channels having a diameter of no more than 8-9 mm or even smaller depending on the size of the needle used. It is noted that each of the tools requires an introduction aperture having a relative large height and small width. Accordingly, a tubular channel will have room for light sources and optical instruments on each side of the tools.